Routine inspection·October 22, 2024

On 10/22/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Noelia Luna, introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Minakshi Roychoudhury was contacted and arrived a short time later. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There is currently 2 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 09/18/2024. Last fire drill on 07/17/2024. Water temperature measured 116.4 degrees F in restroom #2. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets in hallway. Sharps and medications were located in locked cabinets. LPA observed sufficient seating under covered patio areas. The following issues were observed during todays visit: Chemicals observed in 3 of 3 restrooms unlocked and accessible, vents in hallways in need of dusting/air filters, restroom #2 tub in need of cleaning, food in freezer not dated/stored properly, chemicals/items posing a harm in office unlocked and accessible, walls and doors in need of wiping down, chemical observed in resident #6 bedroom, storage area accessible through resident #6 bedroom, chemicals/items posing a harm next to storage shed and outside back door accessible and unlocked, open patio on back of facility observed without railing and lighting posing a hazard, left side gate not self-latching. CONT... CONT... LPA requested the following documents to be submitted to CCL by 10/29/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Deficiencies cited per Title 22 on attached 809D. TV's and TA's provided. Exit interview completed with Administrator, Minakshi. A copy of this report, deficiencies, TV's, TA's and appeal rights provided.